March 28, 2011

Patterns where phlegm –rheum is the primary cause of wheezing and panting

A commonly seen presentation in wheezing and panting is the contraction of an external pathogenic factor with simultaneous retention of phlegm-rheum. In patients who are constitutionally predisposed to phlegm-damp retention, usually the initial attack by an external factor will stir the interior phlegm which will counterflow into the lung, invariably causing the wheezing and panting. This pattern is mentioned in the Shang Han Lun, where it states:

“In cold damage where the exterior is unresolved, (and) there is water qi below the heart….”

In these cases treatment generally involves, effusion to resolve the exterior, with simultaneous warm transformation of fluids. The various manifestations of this condition can be treated with the following prescriptions:

She Gan Ma Huang Tang: (Belamcanda and Ephedra Decoction)

射干麻黄汤

Main signs: Aversion to cold, generalized body pain, copious phlegm, and the sound of phlegm in the back of the throat. If this pattern is accompanied by signs such as a dry mouth, dry tongue, and heart vexation, Sheng Shi Gao may be added.

Xiao Qing Long Tang: (Minor Blue-Green Dragon Decoction)

小青龙汤

Main signs: Aversion to cold, generalized body pain, an absence of sweating, coughing with a need to rest and lean up against something, yet unable to lie down. (This is normally due to the presence of copious phlegm), severe coughing with frothy phlegm. If this is accompanied by signs such as a dry throat, vexation and agitation, Sheng Shi Gao may be added.

Main signs: Aversion to cold, absence of sweating, perhaps an aversion to cold felt in the back, counterflow cold of the extremities, a fatigued spirit, and a deep-thin pulse.

Patterns where blood stasis is the primary cause of wheezing and panting.

Originally when blood stasis is laying dormant in the interior, any changes caused by external contraction, food damage or damage from the seven affects will induce and entice the movement of blood stasis which will eventually invade the liver and lungs and cause wheezing and panting. If this stasis is not eliminated than the wheezing and panting will endure and recovery would be difficult to achieve. Therefore many cases of wheezing and panting due to cold, or summer-heat that fail to resolve, usually contain elements of static blood. The following are a couple formulas that can effectively treat these presentations.

Patterns where both phlegm-rheum and blood stasis are the primary cause

If for example our patient presents with a Xiao Qing Long Tang presentation with elements and signs of Da Chai Hu Tang He Gui Zhi Fu Ling Wan, then these three formulas may be combined.

With difficult bowel movements it is easy to see signs of either Gui Zhi Fu Ling Wan or Tao He Cheng Qi Tang. If in this case a She Gan Ma Huang Tang presentation exists, then the combination of these formulas would be applicable.

If signs of mouth or tongue dryness, or vexation and agitation are seen with the above formulas, then Sheng Shi Gao may be added.

Why Da Chai Hu Tang?

Dr Hu explained that many patients presenting with wheezing and/or panting manifest a Shao-Yang, Yang-Ming combination disease. Therefore, the cardinal Shang Han Lun formula Da Chai Hu Tang (Major Buplureum Decoction) may be used with quite astonishing results. Many of Dr. Hu’s students would often ask him why when treating wheezing he wouldn’t just use Ma Huang (Radix Ephedra)? He would simply state that unless the case presenting was a Ma Huang pattern, its use was not warranted. In the Shang Han Lun (On Cold damage) it states that “In wheezing with chest fullness, Ma Huang is appropriate, but in wheezing with abdominal fullness, Ma Huang should not be used”.

Dr. Hu would explain that in order to diagnose a Shao-Yang Yang-Ming case of wheezing and panting, we need to look for symptoms such as; wheezing and panting with occasional chest fullness, rib-side pain, sweating, dry throat, dry bowel movements, etc.

Posted by
Eran Even

2 comments:

It seems a little odd to me that he says "wheezing and panting with occasional chest fullness" being a key indicator for Shao-Yang Yang-Ming, (where he would not use ma huang) where in the previous sentence he says "In wheezing with chest fullness, Ma Huang is appropriate, " Ideas?

First off, Dr. Hu was obsessed with Da Chai Hu Tang, and after reading dozens of his cases, you see that he REALLY used it a lot!! Occasionally I'll read a case where I can not figure out why he did, but he did, and was successful. Go figure! In previous commentaries regarding wheezing and panting that I've read, he's said that other signs of Shao-Yang and Yang-Ming need to be present in order to use DCHT, such as the typical sub-costal distention, sweating, dry stools, dry throat, bitter taste, etc... and in cases where Ma Huang was used, the typical exterior repletion signs need to be present. A big differentiating factor for Dr. Hu was whether or not abdominal fullness was present,which would warrant the use of Ma Huang or not, as it is written in the Shang Han Lun. You're right, I think to just say "wheezing and panting with occasional fullness......." is far too general and leaves far too much for interpretation. Creating discussion like this is exactly why I put these cases up in the first place, so thanks for your comments and questions Jason.